Preoperative ASES Scores Can Predict Substantial Clinical Benefit at 2 Years Following Total Shoulder Arthroplasty

The variability of MCID, SCB, PASS, and MOI thresholds for PROMs in the reverse total shoulder arthroplasty literature: a systematic review

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) is a common procedure utilized to address degenerative pathologies of the glenohumeral joint and rotator cuff. Increased reliance on patient-reported outcome measures (PROMs) have placed emphasis on the utilization of the minimum clinically important difference (MCID), substantial clinical benefit (SCB), patient acceptable symptom state (PASS), and maximal outcome improvement (MOI) thresholds to assess the clinical efficacy of RTSA. In this study, we systematically reviewed the MCID, SCB, PASS, and MOI thresholds reported for PROMs following RTSA.

METHODS

PubMed, Embase, MEDLINE, Cochrane Library, and Google Scholar were queried for articles from January 1, 2000 to August 31, 2023 reporting MCID, SCB, PASS, or MOI values for PROMs following RTSA. Patient demographic data, study characteristics, MCID/SCB/PASS/MOI thresholds, and threshold calculation methods were extracted.

RESULTS

One hundred and forty-one articles were screened with 39 ultimately included, comprising 11,984 total patients that underwent RTSA. 34 (87%) studies reported MCID thresholds, 20 (51%) reported SCB, 5 (13%) reported PASS, and 2 (5%) reported MOI. 25/39 (64%) studies referenced a previous study when reporting MCID, SCB, PASS, or MOI values, 11 (28%) used an anchor-based method to calculate threshold values, 1 (3%) used a distribution-based method, and 2 (5%) used both anchor and distribution methods. There were 19 newly calculated MCID (11), SCB (5), PASS (1), and MOI (2) thresholds. For 5 of the 6 most utilized PROMs (ASES, SST, Constant, UCLA, and SPADI), the range of reported MCID values exceeded 50% of the most common threshold. For 3 of 6, the range of SCB values exceeded 25% of the most common threshold.

CONCLUSION

There is substantial variability in the MCID and SCB threshold values reported in the RTSA literature. Standardizing the methodologic calculation and utilization of MCID, SCB, PASS, and MOI thresholds for RTSA may allow for improved assessment of PROMs.

Does achieving clinically important thresholds after first shoulder arthroplasty predict similar outcomes of the contralateral shoulder?

BACKGROUND

Patients are increasingly undergoing bilateral total shoulder arthroplasty (TSA). At present, it is unknown whether success after the first TSA is predictive of success after contralateral TSA. We aimed to determine whether exceeding clinically important thresholds of success after primary TSA predicts similar outcomes for subsequent contralateral TSA.

METHODS

We performed a retrospective review of a prospectively collected shoulder arthroplasty database for patients undergoing bilateral primary anatomic (aTSA) or reverse (rTSA) total shoulder arthroplasty since January 2000 with preoperative and 2- or 3-year clinical follow-up. Our primary outcome was whether exceeding clinically important thresholds in the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score for the first TSA was predictive of similar success of the contralateral TSA; thresholds for the ASES score were adopted from prior literature and included the minimal clinically important difference (MCID), the substantial clinical benefit (SCB), 30% of maximal possible improvement (MPI), and the patient acceptable symptomatic state (PASS). The PASS is defined as the highest level of symptom beyond which patients consider themselves well, which may be a better indicator of a patient's quality of life. To determine whether exceeding clinically important thresholds was independently predictive of similar success after second contralateral TSA, we performed multivariable logistic regression adjusted for age at second surgery, sex, BMI, and type of first and second TSA.

RESULTS

Of the 134 patients identified that underwent bilateral shoulder arthroplasty, 65 (49%) had bilateral rTSAs, 45 (34%) had bilateral aTSAs, 21 (16%) underwent aTSA/rTSA, and 3 (2%) underwent rTSA/aTSA. On multivariable logistic regression, exceeding clinically important thresholds after first TSA was not associated with greater odds of achieving thresholds after second TSA when success was evaluated by the MCID, SCB, and 30% MPI. In contrast, exceeding the PASS after first TSA was associated with 5.9 times greater odds (95% confidence interval 2.5-14.4, P < .001) of exceeding the PASS after second TSA. Overall, patients who exceeded the PASS after first TSA exceeded the PASS after second TSA at a higher rate (71% vs. 29%, P < .001); this difference persisted when stratified by type of prosthesis for first and second TSA.

CONCLUSIONS

Patients who achieve the ASES score PASS after first TSA have greater odds of achieving the PASS for the contralateral shoulder regardless of prostheses type.

Patients with poor early clinical outcomes after anatomic total shoulder arthroplasty have sustained poor performance at 2 years from surgery

PURPOSE

We sought to define the risk of persistent shoulder dysfunction after anatomic total shoulder arthroplasty (aTSA) beyond the early postoperative period and identify risk factors for persistent poor performance.

METHODS

We retrospectively identified 144 primary aTSAs performed for primary osteoarthritis with early poor performance and 2-year minimum follow-up. Early poor performance was defined as a postoperative ASES score below the 20th percentile at 3- or 6-months (62 and 72 points, respectively). Persistent poor performance at 2 years was defined as failing to achieve the patient acceptable symptomatic state (PASS) [ASES = 81.7 points].

RESULTS

At 2-year follow-up, 51% (n = 74) of patients with early poor performance at either 3- or 6-month follow-up had persistent poor performance. There was no difference in the rate of persistent poor performance if patients were poor performers at the 3-, 6-month follow-up, or both (50% vs. 49% vs. 56%, P = .795). Of aTSAs achieving the PASS at 2-year follow-up, a greater proportion exceeded the minimal clinically important differences (MCID) [Forward elevation, external rotation, and all outcome scores] and substantial clinical benefit (SCB) [external rotation and all outcome scores] compared to persistent poor performers. However, over half of persistent poor performers still exceeded the MCID for all outcome measures (56-85%). Independent predictors of persistent poor performance were hypertension (2.61 [1.01-6.72], P = .044) and diabetes (5.14 [1.00-26.4], P = .039).

CONCLUSION

Over half of aTSAs with an ASES score < 20th percentile at early follow-up had continued poor shoulder function at 2-years postoperatively. Persistent poor performance was best projected by preoperative hypertension and diabetes.

LEVEL OF EVIDENCE

Level III; Retrospective Cohort Comparison using Large Database; Treatment Study.

Mid-Term Outcomes of Arthroscopic Rotator Cuff Repair in Patients with Rheumatoid Arthritis

OBJECTIVE

The effectiveness of arthroscopic rotator cuff repair (ARCR) on rheumatoid arthritis (RA) patients remains a controversial topic. This study investigates the mid-term outcomes of ARCR in RA patients and identifies the factors influencing clinical efficacy.

METHODS

This retrospective study enrolled RA patients with small or medium rotator cuff tears (RCTs) between February 2014 and February 2019. Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons (ASES), and Constant-Murley scores were collected at each follow-up time. Ultimately, magnetic resonance imaging (MRI) and X-ray were employed to assess rotator cuff integrity and progression of shoulder bone destruction, respectively. Statistical methods used two-way repeated-measures ANOVA or generalized estimation equations.

RESULTS

A total of 157 patients were identified and divided into ARCR (n = 75) and conservative treatment (n = 82) groups. ARCR group continued to be divided into small tear (n = 35) and medium tear (n = 40) groups. At the final, all scores were better in ARCR group than in the conservative treatment group (p < 0.05). A radiographic evaluation of the final follow-up demonstrated that the progression rate in ARCR group (18.67%) was significantly lower than that of the conservative treatment group (39.02%, p < 0.05). In the comparison of the small tear and medium tear groups, all scores increased significantly after surgery (p < 0.05), and the final follow-up scores were better than preoperative scores (p < 0.05) but worse than those of the 6-month postoperative follow-up (p < 0.05). Comparison between the two groups revealed that all scores of the small tear group were significantly better than those of the medium tear group at 6-month postoperative follow-up (p < 0.05). Although the scores of small tear group remained better than those of the medium group at the final postoperative follow-up, the difference was not statistically significant (p > 0.05). Radiographic assessment of the final follow-up demonstrated that the progression rate in the small tear group (8.57%) was significantly lower than that in the medium group (27.50%, p < 0.05), and the retear rate of small tear group (14.29%) was significantly lower than that of the medium tear group (35.00%, p < 0.05).

CONCLUSION

ARCR could effectively improve the quality of life for RA patients with small or medium RCTs, at least in the medium term. Despite the progression of joint destruction in some patients, postoperative retear rates were comparable to those in the general population. ARCR is more likely to benefit RA patients than conservative treatment.

Do patients with poor early clinical outcomes after reverse total shoulder arthroplasty ultimately improve?

BACKGROUND

Although most patients undergoing reverse total shoulder arthroplasty (rTSA) have substantial improvement in pain and function at early follow-up, improvements in pain and range of motion progress more slowly during postoperative rehabilitation in a subset of patients. The purpose of this study was to define a patient's risk of persistent shoulder dysfunction beyond the early postoperative period and identify risk factors for persistent poor performance.

METHODS

We retrospectively reviewed 292 primary rTSAs with early poor performance and a preoperative diagnosis of osteoarthritis, cuff tear arthropathy, or rotator cuff tear from a multicenter database. Early poor performance was defined as a postoperative American Shoulder and Elbow Surgeons (ASES) score below the 20th percentile at 3 months (58 points) or 6 months (65 points) postoperatively. Persistent poor performance at 2 years was defined as failure to achieve the patient acceptable symptomatic state for rTSA (77.3 points for the ASES score). The primary outcome was the rate of persistent poor performance. Secondarily, we compared the clinical outcomes of persistent poor performers vs. shoulders that improved at 2-year follow-up and assessed risk factors for persistent poor performance.

RESULTS

At 2-year follow-up, 61% of patients (n = 178) with poor performance at either 3- or 6-month follow-up had persistent poor performance. The rate increased to 85% if poor performance occurred at both 3- and 6-month follow-up. The minimal clinically important difference and substantial clinical benefit for range of motion and outcome scores were exceeded by early poor performers at rates of 83%-92% and 60%-77%, respectively, at 2-year follow-up. On multivariate logistic regression analysis, independent predictors of persistent poor performance after rTSA were lack of hypertension (odds ratio [OR], 0.27; 95% confidence interval [CI], 0.13-0.57; P < .001), heart disease (OR, 2.89; 95% CI, 1.24-6.77; P = .011), uncemented humeral fixation (OR, 0.11; 95% CI, 0.01-1.18; P = .037), previous shoulder surgery (OR, 2.14; 95% CI, 1.06-4.30; P = .031), lower preoperative ASES score (OR, 0.92; 95% CI, 0.87-0.97; P = .002), and lower preoperative subjective rating of pain at its worst (OR, 0.73; 95% CI, 0.54-0.99; P = .038).

DISCUSSION

Despite the fact that 85% of rTSA patients with an ASES score below the 20th percentile at early follow-up exceeded the minimal clinically important difference for improvement in the ASES score at 2-year clinical follow-up, 61% still had persistent poor performance, with failure to achieve the patient acceptable symptomatic state for the ASES score. Persistent poor performance after rTSA was best predicted by a history of shoulder surgery and a poorer preoperative ASES score. These findings can aid surgeons when counseling patients both preoperatively and postoperatively. In the setting of early poor performance, the risk of persistent poor performance must be balanced against the potential outcomes of revision surgery when considering early surgical intervention.